ReadmissionS and SAFE Transitions of Care
Studies show poor communication during transitions of care leads to increased rates of hospital readmissions and medical errors. In fact, nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days.
To address this problem, hospitals across Minnesota participate in SAFE Transitions of Care. This goal is to improve patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities, long-term care, assisted living, home health, and primary care. With implementation of safe transitions strategies, patients should experience improved care including fewer incidents of delayed care or redundant tests, fewer medication events or missed doses, and reduced readmissions to the hospital. The framework includes a road map of best practices to address patient safety gaps and a tool kit of resources to implement the recommendations.
Minnesota hospitals participated in the pilot project; another 14 formed the first cohort early in 2011 and found this framework to be a template for smooth, safe transitions, which is one component of
reducing readmissions. Participating hospitals also experienced fewer follow-up calls from community providers. Subsequent cohorts complete gap analyses using the Road Map to Safe Transitions.
Minnesota Hospital Association also participated in the Reducing Avoidable Readmissions Effectively (RARE) campaign, which aimed to prevent 4,000 avoidable hospital readmissions during a time period of July 1, 2011 and Dec. 31, 2013.